Surgeons face choices in pediatric orbital cellulitis

Reviewed by César Briceño, MD

Philadelphia-Clinicians treating pediatric orbital cellulitis must carefully balance the risks and benefits of steroids, according to César Briceño, MD.

In orbital cellulitis, one of the biggest dangers is from swelling within the eye socket, said Dr. Briceño, assistant professor of ophthalmology, University of Pennsylvania, Philadelphia.

“There is not a lot of space there, and you can have impingement of important structures, leading to vision loss,” he said.

The swelling in the orbit can be exacerbated by pockets of pus, leading to increased pressure, he said, and antibiotics alone may not reduce the swelling rapidly enough.

Steroids reduce the inflammation, but might hamper the immune response.

“On a theoretical basis you could prolong the infection by treating someone with steroids,” he said. “This is where the medicine is really an art. There are not that many standard criteria to make that decision.”

There have not been adequate clinical trials to provide clear guidance, he said, but noted that the research so far favors careful steroid use. He cited Pushker et al. (Am J Ophthalmol. 2013;156:178-183) and Yen et al. (Ophthal Plast Reconstr Surg. 2005;21:363-366).

In addition to reducing compression, steroids can decrease fibroblast proliferation and thus the risk of scarring that can lead to long-term sequelae, he said.

“When used judiciously steroids can be a way to reduce morbidity in the child, and also reduce costs,” he said. “That’s quite relevant in our current regulatory climate.”

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